1. Value Based Purchasing for Dual Eligibles and MLTSS Programs SNP Alliance Leadership Forum November 3, 2015 Gretchen Ulbee, Manager Special Needs Purchasing Minnesota Department of Human Services Gretchen.Ulbee@state.mn.us

2. Making the Most of the Integration Opportunity! Demographic and cost challenges require joint CMS/State/Plan/Provider efforts toward Triple Aim goals especially designed for Medicare-Medicaid beneficiaries. Decisions made by primary, acute and post acute care providers paid under Medicare continue to drive State Medicaid and LTSS costs. – Circular cost shifting between hospitals and nursing homes – Primary care incentives to place difficult patients in nursing homes instead of home care Opportunities to impact provider incentives and practice patterns are lost when current FFS payment models are simply perpetuated within capitated dual eligible programs Combined Medicare/Medicaid primary, acute and LTSS financing is just the first step: – Rearrange payments and move away from FFS at provider levels – Align service delivery arrangements across primary, acute and long term care services – Create provider level practice and payment incentives

3. MN’s Integrated Care System Partnerships (ICSPs) Minnesota state VBP initiative for seniors and people with disabilities in integrated D- SNP and Medicaid managed care programs: – Expands and builds on long standing MN D-SNP/Provider VBP contracting arrangements and experience in Minnesota Senior Health Options (MSHO) – D-SNP platform leverages Medicare involvement in related state payment reforms – Combined Medicare and Medicaid financing provides opportunity for alignment of financial incentives and VBP arrangements across primary, acute and LTSS – Vehicle for scaling up increased accountability of providers through gain/risk sharing Multiple financial and delivery models tied to a range of defined quality metrics developed by D-SNPs, clinical experts and the state for triple aim goals MCOs/provider partners develop arrangements and submit proposals to state State contract requirements for reporting on quality metrics and financial performance Built into MN D-SNP demo, but not dependent on demonstration authority Began 2013, about 50 SNP/MCO/Provider ICSPs now in operation, results now being reported include reducing ACR, re-hospitalizations, ED use, and costs of care. 3

4. Integrated Medicare Medicaid Financing Enables VBP Across Primary, Acute and MLTSS Pay for Performance – Provider contracts with performance based payments tied to quality metrics, training or care process improvements, including MLTSS providers Medicare D-SNP/Medicaid Care Coordination −Combined PMPMs for Medicare D-SNP/Medicaid MLTSS care coordination −Combined PMPMs for Medicare D-SNP/Medicaid MLTSS care coordination with Medicaid behavioral health case management Medicare D-SNP/Medicaid Care Coordination and Primary Care –Combined Medicaid Health Care Home and Medicaid/Medicare care coordination with Medicare and Medicaid Primary Care –Payout through combined PMPMs −Shared incentive pools and/or performance based payments with providers Care Systems – Integrated financing through ACO like D-SNP subcontracts with provider care systems across Medicare, Medicaid, primary acute and long term care services. – Total cost of care sub-capitations or virtual sub-capitations with shared performance pools across all or most services including MLTSS services – Gain and/or risk sharing with providers including MLTSS providers 4

5. Supports for Successful VBP Requires flexibility in payment and measurements for different types of providers (within some parameters ) Match provider scope, expectations to ability of provider to impact change and take risk: (e.g. many MLTSS providers can’t impact health outcomes but P4P might leverage cooperation in needed areas to improve Star ratings ) Leverage broader contracts to include duals: (e.g. hospitals may not serve enough duals to be interested in dual specific contracts) Facilitate data sharing with providers States can share Medicare FFS and COBA data for non D-SNP duals Engage primary care providers in design and execution along with MLTSS providers Provider education Risk adjustment for fair comparisons Collaborate on limited set of measures to focus results Communicate results and progress (charts and graphs) to states On the Horizon: How will current VBP efforts fit with new FFS Medicare payment models and how will those arrangements play out for dual eligibles? Proposed Medicaid managed care regs include new requirements for Medicaid VBP, watch carefully!

6. Additional Resource Slides

7. MN Payment/Delivery Reform Initiatives Health Care Home (HCH): Medicaid benefit provides additional payments to clinics and practitioners certified by MDH Health Homes: MN Behavioral Health Home option Medicare Managed Care: About 50% of the Medicare market (30% in Cost Plans ) Medicaid Managed Care: Statewide managed care through 8 MCOs, 900,000 members HMO Purchasing Initiatives: Long history of HMO/Provider ACO type subcontracting and Pay for Performance arrangements (P4P) Medicare ACO: Medicare Pioneer and Shared Savings ACOs Medicaid ACO: Integrated Health Partnerships (IHPs): 16 Primary/acute Medicaid ACO delivery models operating both within and outside of Medicaid managed care IHPs for People with Disabilities: In development, partnering with Medicare State Innovation Model (SIM): State’s CMS proposal builds on IHP models to improve care coordination, population health, patient experience and costs Medicare D-SNPs: MN’s MSHO system builds on D-SNP platform for access to Medicare to incorporate payment and delivery reforms through ICSPs. Integrated Care System Partnerships (ICSPs): VBP plan/provider payment and delivery reforms across Medicare, Medicaid and MLTSS designed for dually eligible enrollees, enabled through D-SNPs

8. Examples: Integrated Care System Partnerships Variety of sponsors, target populations and payment models under State criteria ranging from P4P, PMPM payments to extensive sub-capitation Some providers have multiple ICSP designs with multiple D-SNPs/MCOs ICSP examples include: – Medicare/Medicaid ACOs: D-SNP sub-capitates provider for all Medicare, Medicaid and MLTSS services with risk and gain sharing, may include downstream gain sharing with LTC providers (Fairview Partners, GSM) – Integrated Primary Care and Health Care Home (HCH): D-SNP pays combined PMPM for Medicare primary care, D-SNP care coordination, Medicaid cost sharing, Medicaid Health Care Home services and Medicaid MLTSS care coordination with risk/gain sharing, may include P4P against virtual cap for key services such as hospitalizations (Essentia, Bluestone, Mayo) – Accountable Rural Communities for Health: D-SNP shares savings on total cost of care, provides care coordination/HCH capacity grants, PMPM care coordination payments and P4P (applied to rural hospital and related primary care systems, SNFs and Red Lake Band of Ojibwe) – Community Behavioral Health Providers: PMPM for integrated Medicare and Medicaid Care Coordination including Mental Health Targeted Case Management with P4P for specified outcomes (MHR, Guild, Touchstone) – Long Term Care Organizations: P4P tied to key outcome measures (Care Choice, Health Partners Long Term Care Partnership) – Other Agencies: Paid training and measurement of improvement in understanding of advanced directives for members and interpreters, P4P for service centers serving ethnic groups for education and referral on Medication Therapy Management and advanced care planning. 8

9. ICSP Payment Types Payment TypesType AType BType C Type D Model Options Performance rewards: performance pool or pay for performance Primary Care Coordination of Care Payment; or partial sub-capitation for primary care and Care Coordination by PCP or other Care Coordinator within ICSP. Subcapitation or Virtual Capitation for Total Cost of Care across multiple defined services including primary, acute and long term care Alternative Proposals 1.1 MCO contracts with LTC providers and/or Primary Care Providers. OPTION NA 1.2 MCO contracts with Primary Care Providers or Care Systems to include payment for Care Coordination, as an alternative to Health Care Home care coordination fees. NA OPTIONNA 2.0 MCO contracts with provider Care System or a collaborative (primary care providers affiliated with long term care providers) with delegated management of care to the provider Care System or collaborative, using risk/gain/ performance payment models across services. NA OPTIONNA 3.0 MCO contracts with providers under payment arrangements that can provide financial and/or performance incentives for integration /coordination of Chemical and/or Mental Health services with acute / primary care services. May include certified HCH or Health Homes. OPTION NA 4.0 Alternative defined by proposal NA OPTION

10. Top Five ICSP Measures (Seniors) 1)Plan All-Cause Readmissions (PCR) The number of acute inpatient stays during the measurement years that were followed by an acute readmission for any diagnosis within 30 days and the predicated probability of an acute readmission 2)Inpatient Utilization- General Hospital/Acute Care Summarizes utilization of acute inpatient care and services in the following categories: Total inpatient, Medicine, Surgery, and may also be disease specific rather than general hospitalizations 3)Advanced Care Planning/ POLST Percentage of members age 65 or greater who have evidence (i.e.- documentation) of advanced care planning in their medical record at their health care home clinic or nursing facility across a 12 month period 4)Use of High Risk Medications in the Elderly (DAE) Percentage of Medicare members 66 years of age and older who received at least one or two high risk medications 5)Medication Reconciliation Post Discharge (MRP) Percentage of discharges for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge 10